Yellow Nail Syndrome

Definition

Yellow nail syndrome abbreviated as YNS is also referred to as Primary Lymphedema Associated with Yellow Nails and Pleural Effusion, and principally affects the lymphatic system as a result of some damage or blockage.

Its specific characteristics include a triad of symptoms such as the yellowish nail discoloration and some nail dystrophy; presence of primary of peripheral lymphedema; and the pulmonary manifestations of respiratory disorders, such as bronchiectasis with the recurrence of some lower respiratory tract infections, and at times with exudative pleural effusion.

YNS is linked with individuals who have persistent coughing and those with chronic sinusitis. It generally affects adults. Both men and women have equal chances to have YNS. The clinical onset can be from the moment of birth until the period of late adulthood; though most cases show that it typically affects middle aged adults.

YNS is associated with some disease problems such as Hashimoto’s thyroiditis, Raynaud’s disease, malignancy and rheumatical conditions of patients.

Symptoms of Yellow Nail Syndrome

The clinical symptoms of yellow nail syndrome may vary among affected individuals and also varies from time to time.

Symptoms of nails changes:

• Yellow discoloration of the nails
• Nail growth is slowed
• Nails become thicker
• Nails may remain smooth but with cross ridges noted
• Presence of dark nail borders
• Nail humps are noticeable and losing some cuticles
• Pale yellowish or greenish nails with slightly darker edges
• Nail curvature from side to side
• Onycholysis possibly affecting one or more nails

Respiratory symptoms:

• Coughing and sputum production
• Recurrent pleural effusion
• Difficulty of breathing
• Bronchiectasis
• Chronic bronchitis
• Pneumonia
• Chronic sinusitis

Symptoms involving lymphedema:

• Atresia of the lymphatics
• Underdeveloped lymphatics
• Limb lymphedema
• Face, hands, legs and genitals are swollen
• Lim pain and swelling
• Fever with chills
• Lethargy and body malaise

It has to be remembered that some patients may not manifest the triad of symptoms as presented by YNS.

Etiology

The exact cause of yellow nail syndrome is still not known; although YNS can be noted among patients who are diagnosed to have pleural effusions, internal malignancies, sinusitis, chronic bronchiectasis, rheumatoid arthritis and the presence of immunodeficiency syndromes.

Other few cases of YNS occur because of an inherited genetical impairment when there is lymphatic abnormality.  Most of the cases are linked with other associated health problems, or it might be the end result of an anatomical abnormality or functional abnormality that involves the lymphatic drainage.

Diagnosis

The clinical diagnosis of yellow nail syndrome is being made when other possible causes of the problem have been excluded during the assessment and evaluation done by an attending physician.

• Imaging might be recommended to evaluate the pulmonary symptoms of the patient
• Computed tomography of the chest might also be necessary in the presence of pleural effusions or in the sequelae of some recurrent pulmonary infections

Treatment

There is no specific treatment for the problem of yellow nail syndrome. Patients with YNS are mostly given the supportive measures to alleviate the clinical manifestations that they present.

Management for the nails

• Existing changes in the nails does not need treatment as it can resolve spontaneously on its own
• Supplemental use of oral zinc
• Itraconazole pulse therapy
• Supplementation of oral vitamin E
• Application of topical vitamin E which is containing dimethyl sulfoxide
• Application of oil on the nails when topical vitamin E does not work

Management for Lymphedema

• Patients are encouraged to have oral zinc supplementation associated with the problem.

Management for pleural effusions

• Low fat diet
• Prescription of diuretics
• Octreotide which a somastatin analogue that is used for treating chylous pleural effusion type
• Surgical treatment might be necessary such as pleurodesis or pleurectomy; plueroperitoneal shunt or pleurovenous shunt

Complications

Patients with YNS can be at risk for possible complications:

• Life threatening massive pleural effusion surgical procedures
• Pleuroperitoneal shunt may result to an abdominal distention or with severe edema
• Hypoventilation may happen after pleurodesis
• Malnourishment may take place with repeated drainage doien for pleural effusion
• The quality of life may be affected with lymphedema

Prognosis

Half of the cases of patients with nail changes may resolve on its own. Respiratory problems can be managed with medical and surgical approaches. Recurrent plueral effusions are the most known problematic manifestation of YNS

References

1. Yellow nail syndrome – Clinical features, Assessment and diagnosis, Management at http://patient.info/doctor/yellow-nail-syndrome
2. Yellow nail syndrome Epidemiology, Pathology, Clinical presentation, Radiographic features at http://radiopaedia.org/articles/yellow-nail-syndrome
3. Yellow Nail syndrome : Treatments, Misdiagnosis, Home Testing, Deaths, Complications at http://www.rightdiagnosis.com/y/yellow_nail_syndrome/intro.htm
4. Simon RW, Bundi B; Yellow nails, chronic cough, and edema. Am J Med. (2010 Feb). 123(2):125-6.
5. Gregoriou S, Argyriou G, Larios G, et al (2008 Aug) Nail disorders and systemic disease: what the nails tell us. J Fam Pract. 57(8):509-14.
6. Rapini, Ronald P.; Bolognia, Jean L.; Jorizzo, Joseph L. (2007). Dermatology: 2-Volume Set. St. Louis: Mosby. p. 1020.